Healthcare Provider Details

I. General information

NPI: 1770073694
Provider Name (Legal Business Name): DEVIN BRUCE SIMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912
US

IV. Provider business mailing address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

V. Phone/Fax

Practice location:
  • Phone: 517-432-9277
  • Fax: 517-432-9414
Mailing address:
  • Phone: 517-432-9277
  • Fax: 517-432-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023-00264
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number5315091709
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2023-00264
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number2023-00264
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: